Midline Cleft Lip and Bifid Nose Deformity: Description, Classification, and Treatment.

BACKGROUND: Midline facial clefts are rare and challenging deformities caused by failure of fusion of the medial nasal prominences. These anomalies vary in severity, and may include microform lines or midline lip notching, incomplete or complete labial clefting, nasal bifidity, or severe craniofacial bony and soft tissue anomalies with orbital hypertelorism and frontoethmoidal encephaloceles. In this study, the authors present 4 cases, classify the spectrum of midline cleft anomalies, and review our technical approaches to the surgical correction of midline cleft lip and bifid nasal deformities. Embryology and associated anomalies are discussed. METHODS: The authors retrospectively reviewed our experience with 4 cases of midline cleft lip with and without nasal deformities of varied complexity. In addition, a comprehensive literature search was performed, identifying studies published relating to midline cleft lip and/or bifid nose deformities. Our assessment of the anomalies in our series, in conjunction with published reports, was used to establish a 5-tiered classification system. Technical approaches and clinical reports are described. RESULTS: Functional and aesthetic anatomic correction was successfully achieved in each case without complication. A classification and treatment strategy for the treatment of midline cleft lip and bifid nose deformity is presented. CONCLUSIONS: The successful treatment of midline cleft lip and bifid nose deformities first requires the identification and classification of the wide variety of anomalies. With exposure of abnormal nasolabial anatomy, the excision of redundant skin and soft tissue, anatomic approximation of cartilaginous elements, orbicularis oris muscle repair, and craniofacial osteotomy and reduction as indicated, a single-stage correction of midline cleft lip and bifid nasal deformity can be safely and effectively achieved.

Tuberous breast deformity: classification and treatment strategy for improving consistency in aesthetic correction.

BACKGROUND: Tuberous breast deformity is a common congenital anomaly with varying degrees of constriction, hypoplasia, skin deficiency, areolar herniation, and asymmetry that poses challenges to consistency in aesthetic correction. In this study, the authors classify tuberous breast deformities, and evaluate their techniques used for treatment. METHODS: Twenty-six patients (51 breasts) treated from 2008 to 2012 were included. Mean patient age was 25 years (range, 18 to 39 years). Cases were classified using a three-tier system. A periareolar approach and glandular scoring maneuvers were used in all cases. Prosthetic placement (implant or tissue expander) was subpectoral (dual-plane) in all cases. The selection of one- versus two-stage correction and mastopexy techniques is presented with reference to the specific deformities in each tier. RESULTS: Mean follow-up was 22 months (range, 8 to 37 months). Twelve type I, 26 type II, and 13 type III deformities were treated. Periareolar incisions only were used in two (4 percent). Circumareolar mastopexy was used in 49 (96 percent), and vertical mastopexy was used in four (8 percent). One-stage correction was achieved in 47 (92 percent); four (8 percent) were treated in two stages with tissue expansion. The global complication rate for all patients in this study is 7.8 percent-two breasts (3.9 percent) had capsular contracture, and two (3.9 percent) had postoperative malposition. CONCLUSION: The authors' experience demonstrates that satisfactory results can be obtained with appropriate classification and treatment of tuberous breast deformity with periareolar access, glandular scoring, subpectoral implant placement, and mastopexy techniques tailored to the specific deformity type. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The circumferential thigh lift and vertical extension circumferential thigh lift: maximizing aesthetics and safety in lower extremity contouring.

Excess skin and soft tissue of the thighs after massive weight loss (MWL) can present with varying degrees of severity. The classic medial thigh lift has considerable limitations in the postbariatric population, inspiring the quest for safer and more effective technical solutions. In this study, the circumferential thigh lift (CTL), and CTL with vertical extension, predicated on a theoretical and technical approach that improves safety and aesthetics in thighplasty after MWL, is described and evaluated. Nine patients were treated; all patients experienced MWL and all had previously undergone first-stage contouring with circumferential abdominal dermolipectomy. Patients were treated with a prone-to-supine approach with concomitant suction-assisted lipectomy (SAL). Lumbar and lateral thigh and infragluteal skin and fat were excised to the midaxillary lines and medial thigh meridians. Direct excision of anterolateral thigh skin was carried in a superficial plane into the medial thigh to confluence with the posterior excision. No direct undermining of any skin margin was performed. When soft-tissue excess is limited to the proximal third of the thigh, a horizontal excision pattern is used; with middle and lower one-third thigh excess, a vertical extension is employed. The medial superficial fascial system is anchored to the superficial perineal fascia. Data were reviewed retrospectively. In the 9 procedures performed, 3 achieved MWL by nonsurgical means, and 6 underwent bariatric surgery (bypass or band). Three patients were treated with CTL, and 6 with CTL with vertical extension. There were 3 seromas (33%) treated with percutaneous aspiration. There was 1 case of cellulitis (11%) treated successfully with in-office incision and drainage, and oral antibiotics. There were no hematomas, skin loss, wound dehiscences, lymphedema, or vulvar distortions. The circumferential excision of thigh excess without direct undermining allows for the maintenance of a rich blood supply to skin margins, and concomitant SAL improves thigh contour while providing discontinuous thigh undermining. Anchoring of the superficial fascial system to superficial perineal fascia reinforces the medial lift and prevents scar migration. CTL with or without vertical extension can be combined with SAL to maximize safety and aesthetic results after MWL.

Endoscopic-assisted transaxillary breast augmentation: minimizing complications and maximizing results with improvements in patient selection and technique.

The use of the transaxillary incision has enabled augmentation mammoplasty with a scarless breast. However, the classic technique has been associated with high rates of asymmetry, malposition, and high riding implants. With the addition of endoscopic assistance, retropectoral pocket visualization and better control of the lower pole has been facilitated. Nevertheless, pitfalls in patient selection and technique abound. In this study, the authors experience with endoscopic transaxillary breast augmentation is reviewed, with particular attention to both the anatomic characteristics associated with favorable and unfavorable outcomes and technical nuances that have improved aesthetic results. One hundred and ninety-seven endoscopic transaxillary breast augmentations were performed during this study. All patients underwent augmentation with saline implants, with a mean volume of 298 mL. Preoperative pseudoptosis or grade I ptosis was present in 14 patients, and 4 patients had mild or moderate tuberous deformity. Thirty-four patients had short lower pole anatomy, with areola-to-inframammary crease length of < or =3.5 cm. There were 19 patients identified with pectoralis major hypertrophy resulting from strength training. One patient (0.5%) required conversion to an open technique for control of bleeding. Three patients (1.5%) required intraoperative conversion to an open technique for inadequate implant position and breast shape (2 with tuberous deformities and 1 with ptosis). Seven patients (3.5%) underwent revision for malposition (5 superior and 2 inferior). There were no infections, seromas, postoperative hematomas, or significant encapsulations. Patient selection is of paramount importance in minimizing complications and optimizing the results of endoscopic-assisted transaxillary breast augmentation. Patients with deficient lower breast poles, sharply defined inframammary creases with short areola-to-fold distances, pectoralis major muscular hypertrophy, ptosis or pseudoptosis, and any form of tuberous breast deformity should be identified carefully and considered judiciously. Technical refinements that maximize safety and improve the aesthetic results with endoscopic-assisted transaxillary breast augmentation are described.

Maximizing aesthetics and safety in circumferential-incision lower body lift with selective undermining and liposuction.

Circumferential dermolipectomy has been an effective means of reducing excess skin and fat after massive weight loss, however, regions of residual midabdominal and epigastric fat frequently confer a suboptimal contour, and often mediocre cosmetic results. Liposuction in association with lower body lift surgery has been regarded with caution, for fear of ischemia or necrosis of the undermined flaps as potential dire consequences. In this study, a theoretical and technical approach that maximizes safety and aesthetics in circumferential lower body lift after massive weight loss with contouring using liposuction is described and evaluated. Twenty-four patients were treated with follow-up ranging from 6 to 40 months (mean follow-up 17 months). All patients were treated with the resection of circumferential skin and fat maintaining a low-lying transverse suture line with a prone-to-supine approach. Dorsally, liberal liposuction is performed after the instillation of lidocaine-free wetting solution above and below the resection lines. Ventrally, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised, and the dissection then progresses in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal "perforator zone" of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Wetting solution is instilled, and suction-assisted lipoplasty of the entire flap, particularly in the midline and in the region of the neo-umbilicus, is performed, removing excess fat and providing discontinuous lateral flap "undermining." There was 1 hematoma (4%) requiring re-exploration and 4 seromas (17%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Unlike standard dermolipectomy procedures with wide undermining, the maintenance of a broad subcostal blood supply with selective direct undermining allows for liberal flap contouring with suction and the establishment of lower suture-line position. With this technique, liposuction can be safely used during lower body lift to maximize aesthetic outcomes.

Minimally invasive correction of inverted nipples: a safe and simple technique for reliable, sustainable projection.

Numerous techniques have been described for the correction of inverted nipples; their diversity supports the lack of a consistently reliable method. Dermoglandular flaps, open suture, and suction techniques have all been described to combat the "corrected" nipple's propensity to collapse. We present a minimally invasive parenchymal release and percutaneous suture technique that provides sustainable long-term correction of inverted nipples. Thirty-one patients with 58 inverted nipples were treated. The technique, performed under local anesthesia, employs lysis of the foreshortened subareolar fibro-ductal tissue to achieve resting eversion of the nipple using an 18-gauge needle. Through the same needle-access site, a purse-string suture is then placed, exiting the areolar skin and re-entering through the same stitch point every 3 to 5 mm around the circumference of the new nipple-base. An absorbable suture closes the access site over the knot, and 2 crossed absorbable mattress sutures are placed beneath the nipple to complete the correction. Of 27 patients with bilateral and 4 with unilateral, nipple inversion, durable correction was achieved in 1 procedure in 45 of 58 nipples (78%). There were 13 recurrences, of which 11 (19%) were successfully treated under local anesthesia with a second purse-string suture, and 2 (3%) required a third procedure under local anesthesia. There were no late reinversions. There were no cases of infection, nipple ischemia, or other complications. Occasional recurrences are corrected very simply under local anesthesia. Percutaneous release of nipple inversion followed by purse-string suture support performed through "needle-only" access points is a simple, safe, and reliable technique, and should be considered for the correction of inverted nipples.

Improving esthetics and safety in abdominoplasty with broad lateral subcostal perforator preservation and contouring with liposuction.

Suction-assisted lipectomy (SAL) in association with abdominoplasty has been regarded with trepidation, with ischemia of the apron flap, skin loss, and open wounds among the potential dire consequences. Leaving midabdominal and epigastric fatty excess, however, confers suboptimal contour and often a mediocre cosmetic result. In this study, a theoretical and technical approach that improves esthetics and safety in anterior and circumferential abdominoplasty with contouring using SAL is described and evaluated. Forty-two patients were treated with follow-up ranging from 5 to 40 months (mean follow-up 19 months). Through a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised. The dissection then proceeds in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal "perforator zone" of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Excess skin and fat are excised from the inferior aspect of the flap, and the flap is inset. Wetting solution is instilled, and SAL of the entire flap, particularly in the midline and in the region of the neoumbilicus, is performed. Data were reviewed retrospectively. Twenty-seven anterior and 15 circumferential procedures were performed. There were 36 females and 6 males. There was one hematoma (3%) requiring re-exploration (male, circumferential), and 3 seromas (7%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Contrary to classic abdominoplasty undermining to the costal margins, the maintenance of a broad subcostal blood supply allows for liberal flap contouring with suction. With this technique, liposuction can be safely used in abdominoplasty to maximize esthetic outcomes.

Salvage of exposed implantable cardiac electrical devices and lead systems with pocket change and local flap coverage.

Erosion and exposure of pacemaker (PPM) and implantable cardiac defibrillator (ICD) devices are potentially dire complications, which have classically required the removal of the entire generator and lead systems. This study evaluates a series of cases wherein debridement, irrigation, pocket change, and local flap coverage were used for the successful salvage of indwelling leads after exposure and infection of implantable cardiac defibrillator devices. Patients with skin erosion, infection, and/or exposure of prepectoral infraclavicular cardiac defibrillator devices were treated over a 23-month period between June 2004 and April 2006. The surgical technique involved wide excision of the exposure site with a rhombic incision pattern, followed by removal of the generator unit and complete debridement of the peridevice capsule. Subclavian atrioventricular (AV) leads were preserved. The pocket was irrigated with antibiotic solution. A new pocket plane was selected and developed, and a new generator unit was implanted. A rhombic flap was developed and transposed to achieve tension-free closure over closed suction drains. Data were reviewed retrospectively. Six patients were treated, all male, mean age 66 years (range, 50 to 83 years). All patients presented with "new" exposure of the implantable generator within 48 hours. None demonstrated gross purulence, sepsis, or endocarditis. Initial gram stain was negative for bacteria in all cases, 1 (17%) grew sensitive Staphylococcus epidermidis species. Mean follow-up is 22 months (range, 8 to 31 months). One patient (17%) developed a hematoma, successfully treated by aspiration. Five patients (83%) were treated successfully, with no wound dehiscence, generator or lead exposure, or recurrence of infection. One patient (17%) developed drainage and exposure at a separate site (AV lead) at 10 months postoperative and required generator and lead explantation and site change to the contralateral anterior chest wall. In conclusion, in the absence of sepsis or gross infection, skin excision, pocket change, generator change with lead preservation, closed-suction drainage, and flap coverage for tension-free closure should be considered in the treatment of early ICD and PPM exposure.

Multilayer reconstruction of abdominal wall defects with acellular dermal allograft (AlloDerm) and component separation.

Multiple techniques have been employed for the repair of abdominal incisional hernias with varying rates of success. Primary fascial apposition and prosthetic implantation have been associated with high rates of secondary recurrence, infection, and other complications, often due to insufficient alleviation of tension and implant intolerance. This study evaluates the repair of incisional and recurrent abdominal hernias with multilayered acellular dermal allograft (AlloDerm; LifeCell Corporation, Branchburg, NJ) and musculofascial separation. Patients with incisional or recurrent abdominal hernias were treated between January 2003 and March 2004. The surgical technique involved musculofascial release of the external oblique, followed by a double-layer implantation of dermal allograft. The primary allograft layer was placed as an "underlay" interposition, sutured under moderate tension beneath the fascial edges of the defect. When minimal tension remained, the native fascial margins of the defect were directly repaired. A second allograft layer was then placed and sutured to the superficial aspect of the ventral fascia to complete the repair. Data were reviewed retrospectively. Sixteen patients were treated. There were 10 males and 6 females, mean age 56 years (range 44--72 years). Fifteen patients (94%) had previous hernia repair procedures, and 6 patients (38%) had undergone 2 or more previous procedures. Nine patients (56%) were treated with hernia site infections or prosthetic exposure. Mean follow-up is 16 months (range 9 to 23 months). There were 2 seromas (13%). One patient (6%) developed a wound dehiscence with allograft exposure that healed by secondary intention. There were no recurrences. By minimizing tension and providing a durable biocompatible matrix for support, component separation with bilaminar acellular dermal allograft should be considered for the repair of complex and recurrent ventral hernias.